Provider Demographics
NPI:1083610034
Name:JARECKI, DAVID A (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:JARECKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E CONAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1394
Mailing Address - Country:US
Mailing Address - Phone:218-365-5556
Mailing Address - Fax:218-365-3888
Practice Address - Street 1:102 E CONAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1394
Practice Address - Country:US
Practice Address - Phone:218-365-5556
Practice Address - Fax:218-365-3888
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6401457Medicaid
MN6401457Medicaid